<!DOCTYPE html>

<html>

    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"/>
        <title>Web Form</title>
        <script src="../raxan/startup.js" type="text/javascript"></script>
        <script src="views/scripts/css-webform.js" type="text/javascript"></script>
        <style type="text/css">
            .impress {
                background: #DDE8AE;
                border: 1px solid #fff;
                border-left:2px solid #C6D880;
                border-top:2px solid #C6D880;
                padding:5px;
            }
        </style>
    </head>

    <body>

        <div class="container c30 tpm">
            <form id="frmStudent">

                <div class="rax-box success c23">
                    <h4 class="box-title">General</h4>
                    <div class="pad clear">
                        <div id="pnlError" class="rax-box alert bmm hide clip">
                            The following fields are required:
                        </div>

                        <div>
                            <label class="left">First Name:<br /><input id="txtFName" name="txtFName" type="text" size="30"  /></label>
                            <label class="left ltm">Last Name:<br /><input id="txtLName" name="txtLName" type="text" size="30"  /></label><br />
                            <label class="left">Street:<br /><input id="txtStreet" name="txtStreet" type="text" size="40"  /></label>
                            <label class="left ltm">City:<br /><input id="txtCity" name="txtCity" type="text" size="20"  /></label><br />
                            <label class="left">State:<br />
                                <select name="lstCountry" class="c8">
                                    <option>Brazil</option>
                                    <option>Canada</option>
                                    <option>France</option>
                                    <option>Jamaica</option>
                                    <option>United States</option>
                                    <option>United Kingdom</option>

                                </select></label>
                            <label class="left ltm">State:<br /><input id="txtState" name="txtState" type="text" size="20"  /></label>
                            <label class="left ltm">Zip:<br /><input id="txtZip" name="txtZip" type="text" size="11"  /></label>
                        </div>

                        <hr class="space" />

                        <div class="impress" align="right">
                            <strong>Contact Via: </strong>&nbsp;
                            <label><input name="chkFeatures" type="checkbox" value="phone" /> Phone</label>&nbsp;
                            <label><input name="chkFeatures1" type="checkbox" value="email" /> Email</label>&nbsp;
                            <label><input name="chkFeatures2" type="checkbox" value="fax" /> Fax</label>&nbsp;
                        </div>
                        <div class="clear"></div>
                    </div>

                    <div class="hlf-pad " align="right">
                        <div id="status" class="left"></div>
                        <input id="btnSave" class="button process" type="button" value="Save" />&nbsp;
                        <input id="btnCancel" class="button cancel" type="button" value="Cancel" />
                    </div>
                </div>

            </form>

        </div>

    </body>

</html>
